Cover Image

PAPERBACK
$59.75



View/Hide Left Panel

10
A Patient Outcomes Orientation: A Response

John E. Wennberg

First I would like to take this opportunity to thank Albert Mulley for doing so much work in this area. The whole idea of the interactive video disk approach as a means for informing patients about what happens was his idea. He hit upon it one night when we were walking in Santa Monica. His idea was to let the second opinion be the patient's. Since that time we have gone quite a long way toward clarifying the intellectual basis for involving the patient actively in the decisionmaking process. The more we engage this issue, the more optimistic I am that some of the major problems now confronting our medical policy have a solution that goes back to the question of patient demand. I have always been skeptical about the notion that our cost containment crisis was a product of patient demand and medical progress, being much more impressed by the features of supplier-induced demand and professional uncertainty about the value of medical treatments—the fact that physicians often disagree on what works in medicine. Perhaps, through outcomes research and communication with patients, we can learn what the demand for care really is.

OUTCOMES OF CARE

One of the more important recent policy events, one that happened during the period of deliberations by this Institute of Medicine (IOM) committee, is that we now have a new agency called the Agency for Health Care Policy and Research (AHCPR). This agency offers, for the first time, a focus in government for the systematic evaluation of different medical theories. Much of our uncertainty about what works in medicine comes from the fact that we simply have not undertaken the kinds of studies that Mulley (1991) presents—studies to find out what the probabilities are for the various



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 73
Medicare: New Directions in Quality Assurance 10 A Patient Outcomes Orientation: A Response John E. Wennberg First I would like to take this opportunity to thank Albert Mulley for doing so much work in this area. The whole idea of the interactive video disk approach as a means for informing patients about what happens was his idea. He hit upon it one night when we were walking in Santa Monica. His idea was to let the second opinion be the patient's. Since that time we have gone quite a long way toward clarifying the intellectual basis for involving the patient actively in the decisionmaking process. The more we engage this issue, the more optimistic I am that some of the major problems now confronting our medical policy have a solution that goes back to the question of patient demand. I have always been skeptical about the notion that our cost containment crisis was a product of patient demand and medical progress, being much more impressed by the features of supplier-induced demand and professional uncertainty about the value of medical treatments—the fact that physicians often disagree on what works in medicine. Perhaps, through outcomes research and communication with patients, we can learn what the demand for care really is. OUTCOMES OF CARE One of the more important recent policy events, one that happened during the period of deliberations by this Institute of Medicine (IOM) committee, is that we now have a new agency called the Agency for Health Care Policy and Research (AHCPR). This agency offers, for the first time, a focus in government for the systematic evaluation of different medical theories. Much of our uncertainty about what works in medicine comes from the fact that we simply have not undertaken the kinds of studies that Mulley (1991) presents—studies to find out what the probabilities are for the various

OCR for page 73
Medicare: New Directions in Quality Assurance outcomes given a particular course of treatment. By virtue of this neglect, physicians have not had the probability estimates at hand to inform patients about theft likely outcomes. A fundamental dimension in the IOM committee's definition of quality (IOM, 1990), namely the likelihood of an outcome, is not now understood in any systematic way. Because of the influence of the new agency, in the next few years we will come to understand much better what works in medicine; I will return to this point below. The IOM committee's definition also includes the idea of a desired health outcome. I think we are now in a position to begin to learn what it is that patients actually want in medicine as opposed to what they have used. Most economists and policy analysts have in the past confused utilization with demand, as if the rate of service use expressed the wants of patients. Now we know from the small-area variation studies and from all we have learned about the scientific weaknesses in medicine that utilization does not necessarily indicate what patients want. APPROPRIATENESS OF CARE In Paul Griner's paper (Griner, 1991), I am struck by the use of the word "appropriate." This word has always been a problem for me. When I was on the house staff at Johns Hopkins, my chief of medicine and other senior clinicians were always telling the house staff what was appropriate, which usually meant what they wanted us to do. Although their theories were very plausible, many were not tested; they were simply part of the conventional wisdom of the day. At that time, for example, it was appropriate, particularly at Hopkins where Dr. Halstead had invented the idea, to do a radical mastectomy for women diagnosed with breast cancer. We now know that this theory was hardly appropriate, if by the word appropriate we mean something that patients want based on knowledge about outcomes. In our search for definitions, therefore, modification is needed. As a house staff officer, we thought the words appropriate care meant necessary care. If it is inappropriate, then it is unnecessary care. Now we know that medicine is much more complex, that there are multiple morbidities, multiple treatments, and multiple outcomes. Care is appropriate only if two conditions exist: (1) it works in some important dimensions of the multiple-morbidity, multiple-outcomes complex; and (2) patients prefer this treatment and these outcome probabilities among those offered by the alternatives. When these conditions are met, it seems fair to say that care is appropriate. Care that patients do not want is not appropriate, even though it may be effective. PATIENT VALUES I want to elaborate a bit on this notion of choice between valid treatments. As we completed our assessment of watchful waiting and surgery as

OCR for page 73
Medicare: New Directions in Quality Assurance options for treating benign prostatic hypertrophy (BPH), the predicament patients face became clear. Transurethral prostatectomy worked better than watchful waiting for relief of symptoms, but it has, as Mulley (1991) noted, its down sides. It causes death in some people; it causes incontinence and impotence in others. People will value these different possible outcomes differently depending on their life situations. The problem we faced was how to make this information available to patients in ways that allowed them actively to participate in their choice of treatment, in this case surgery. Our strategy in laying this out to patients was to try to make it crystal clear to them that they have an option. To do this we used interactive video disk technology, which allowed us to show specific patients what their outcome probabilities are, to inform them that they really do have a choice, and to show them vignettes of their possible futures through interviews with patients who had various outcomes. The heuristic we used to establish that the choice is up to the patient was to interview two physicians, both of whom were severely symptomatic. One chose surgery because of his particular attitude toward his symptoms and toward risk. The other, having similarly severe symptoms, was more concerned about incontinence than about his symptoms and he, therefore, chose watchful waiting. Interactive disk technology works. When informed about the fact that they do have a choice, patients actively participate in the decision process. Some of our more successful experiences to date are among Veterans' Administration hospital patients, a group that many would suppose is uninterested in sharing decisionmaking. Virtually all patients, regardless of socioeconomic status, actively seek information. When they are empowered by the idea that they have a choice, they insist on participating in the decision. We have been very much gratified and somewhat surprised by that finding. FUTURE ADVANCES IN DECISIONMAKING Over the next three or four years I think outcomes research will develop the probability estimates required to clarify the decision problems for 10 to 15 major choices, such as bypass surgery, joint replacement, hysterectomy, and back surgery. This will allow us to do for other common conditions what it has been possible to do for BPH, namely, to clarify the outcome probabilities and begin to bring that information to patients and physicians to improve the scientific and ethical basis of clinical decisionmaking. I predict that, as in the BPH example, most of the conditions will provide people with clear choices between treatments depending on their attitudes toward risk and their concern about various outcome states. About 10 conditions represent well over 60 percent of inpatient surgery in the United States these days. If we begin to translate these data into information that patients can understand and present it to them in ways that they can act upon, we will begin to learn what demand really exists in

OCR for page 73
Medicare: New Directions in Quality Assurance medicine for high-technology interventions. This should greatly assist the entire quality effort because it will provide a foundation for beginning to develop the methods for implementing this broadly in clinical practice. On the basis of our work so far, I would not be at all surprised to see that the aggregate demand for surgery is less than the quantity now supplied. Our early results in the use of this approach show that patients tend to be more averse to risk than physicians; hence, they tend to select more conservative treatment. Whether this will be so in the long run is not clear, but at least we will learn what patients really want. OUTCOMES RESEARCH The outcomes research agenda will help the quality agenda in one other important way, dealing with an entirely different kind of problem. This is one in which the capacity of the system influences the clinical thresholds that, in turn, affect the probability of hospital admission among various communities. One of the more important insights of medical care epidemiology is that when the number of hospital beds varies between communities, as it does, for instance, between Boston (4.5 beds per 1,000) and New Haven (2.9 per 1,000), beds in higher-bed areas are used almost exclusively to treat patients with a set of medical conditions that I have come to call ''high variation.'' Surgical procedure rates are not correlated with bed supply, nor are the admission rates for heart attacks, strokes, and acute gastrointestinal hemorrhages. The kind of admissions that are more frequent when beds are more common are pneumonias, bronchitis and asthma, otitis media, and hypertension. For example, the most important single reason for the difference in rates of use between Boston and New Haven is the number of hospital admissions for people with chronic back pain—not surgical patients but medical patients. Associated with the increasing bed supply are three factors: (1) a tendency to put more resources into terminal illnesses (40 percent of people in Boston die in the hospital compared to 31 percent in New Haven); (2) to spend a lot more per case (the per capita cost for terminal illnesses in Boston is 2.5 times higher than in New Haven); and (3) to readmit people with chronic conditions. At least in the Boston-New Haven situation, outcomes research has already been able to show no detectable differences in mortality rates between these two communities despite their extraordinary differences in investment of resources. Further research will show whether there are differences in morbidity, differences in quality of life, or differences in symptom levels that can be associated with this extraordinary difference in resources. The null hypothesis may well hold, in which case there is a very interesting opportunity for massive reallocation of resources toward more effective services.

OCR for page 73
Medicare: New Directions in Quality Assurance Remember that the theories that are associated with bed supply are implicit theories, theories that clinicians in New Haven do not even recognize as existing. Occupancy rates for the hospitals in New Haven are the same as in Boston, and New Haven physicians do not believe they are rationing or withholding care. Contrast this to the situation of Cody Howard in Oregon, who was a victim of the assumptions that medical progress and patient demand are at the heart of the cost containment crisis and that, therefore, we have to ration care. Contrast his situation where potentially lifesaving bone marrow transplantation was withheld on the basis that we could not afford it. Within three to four years we should know a good deal more about the outcomes of many of our common strategies for allocating resources, and we should be in a position to entertain seriously the idea of reallocation. QUALITY, RESOURCES, AND PRACTICE PATTERNS When I read the IOM report, I agreed with its message, but I did not see in it mechanisms by which the quality movement could affect the overall aggregate supply in market areas. Yet, if we are going to achieve reallocation, we are going to have to pay close attention to the question of whether structural changes are actually harming patients. Inevitably, there will be disagreements and conflicts in the profession as these issues are dealt with more explicitly. Finally, I want to draw attention to another observation I have made. In medical markets, theory and supply seem to be in dynamic equilibrium. The threshold effect of the use of hospital beds is a very good example of that. In areas where there are more surgeons who prefer, for example, endarterectomy theories for treating carotid stenosis, there will be more operations. In areas where there are more neurologists preferring aspirin treatment for that condition, there will be more medical management. We need to come to terms with the fact that the supply of resources and the theories that physicians use in practice are in dynamic equilibrium, and they both affect practice style. I bring this up at this point only to remind you that over the next few years we must learn how to deal explicitly with the capacity problem if we are going to make the gains that we want from our outcomes research and our efforts to improve the quality of care. REFERENCES Griner, P.F. Improved Decisionmaking by Patients and Clinicians: The Committee View. Pp. 48-53 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

OCR for page 73
Medicare: New Directions in Quality Assurance Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. Mulley, A.G. A Patient Outcomes Orientation: The Committee View. Pp. 63-72 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N. eds. Washington, D.C.: National Academy Press, 1991.